heart disease

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It’s so very disconcerting when deeply entrenched health wisdom is suddenly flipped on its head. But that’s the way it often goes in this arena.

The Comedian/flickr

So, with such widespread confusion over the new guidelines on cholesterol and statins, cholesterol-lowering drugs, I was relieved to see that veteran health reporter (and my former colleague) Ron Winslow at The Wall Street Journal offered a just-the-facts-ma’am Q & A on exactly what you need to know about the new guidelines. It’s got everything from LDLs to the new risk calculator — which was down when I checked this morning. (What’s going on with all the bugs in our critcal health care sites??)

Here’s a snippet from Winslow:

The new tack recommended by the American Heart Association and the American College of Cardiology is to prescribe moderate to high doses of cholesterol-lowering drugs called statins to patients who fall into one of four risk groups regardless of their LDL status. Here is a look at the implications:

Q. Why get rid of the LDL targets?

A. The targets lack strong scientific evidence. The expert panel that developed the guidelines concluded that by focusing on an individual patient’s overall risk rather than a relatively arbitrary set of LDL targets, the strategy to prevent heart attacks and strokes will be more effective and more personally tailored to the needs and preferences of each patient.

Q. What should patients do in response?

A. Patients already on cholesterol-lowering medication should ask their doctors at their next appointment whether they are on the most appropriate therapy to reduce their heart-attack and stroke risk, says Neil Stone, a cardiologist at Northwestern University who headed the panel that wrote the cholesterol guideline.

For people not on cholesterol drugs, a new risk calculator is available online. If you have a 7.5% chance of having a heart attack over the next 10 years, you are a candidate for treatment with a statin no matter your LDL level under the new guidelines.

Q. I have no heart problems and my LDL was 90 in a recent cholesterol test. Is it possible I should be on a statin anyway? Continue reading →

In my house, there’s a little sticker over the sink that says: “Exercise before showering!”

We don’t always abide by that, but we always aspire to it.

And here’s yet another rational analysis to back us up: new research published in the BMJ concludes that physical activity looks to be as effective as many drugs for patients with existing heart disease or stroke.

Exercise, say the study authors, “should be considered as a viable alternative to, or alongside, drug therapy.”

From the paper:

Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

(Matthew Kenwrick/Flickr)

Here’s more from the BMJ news release:

Physical activity has well documented health benefits, yet in the UK, only 14% of adults exercise regularly, with roughly one third of adults in England meeting recommended levels of physical activity. In contrast, prescription drug rates continue to skyrocket, sharply rising to an average of 17.7 prescriptions for every person in England in 2010, compared with 11.2 in 2000.

But there is very little evidence on how exercise compares with drugs in reducing the risk of death for common diseases.

So researchers based at the London School of Economics, Harvard Pilgrim Health Care Institute at Harvard Medical School and Stanford University School of Medicine set out to compare the effectiveness of exercise versus drugs on mortality across four conditions (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure and prevention of diabetes).

September 27, 2013 | 1:48 PM | Karen Weintraub

Cavemen didn’t have flat feet or type 2 diabetes. They didn’t need orthodontia or get impacted wisdom teeth. The ones who couldn’t see their prey – or predators – from far away didn’t live long enough to pass their nearsightedness on to their children.

Indeed, the vast majority of what ails us today — from leading killers like heart disease and cancer, to smaller health woes such as back pain — is the result of a mismatch between the environments we evolved in and the ones we now inhabit, argues Harvard evolutionary biologist Dan Lieberman in his sweeping new book, “The Story of the Human Body: Evolution, Health, And Disease.”

Lord Jim/flickr

Lieberman, perhaps best known for his energetic advocacy of barefoot running (which he sometimes does), convincingly makes the case for a wholesale rethinking of how we live our modern lives based on overcoming these evolutionary “mismatches.”

“Most of us in this room are probably going to die of a mismatch disease,” Lieberman told a capacity crowd Thursday night at the Harvard Museum of Natural History.

Our bodies evolved as hunter-gatherers to walk 5-10 miles a day, eat a varied diet loaded with fiber and pack on fat in times of plenty to get us through the leaner times, he said. But instead, we live in an environment where we can drive to the mall, park close to the door and take the escalator up to the food court for a dinner that barely needs chewing.

This mismatch has led, he suggests, to a proliferation of heart disease, cancer and diabetes – which were nearly unknown to our prehistoric ancestors, as well as disabling conditions like low back pain and autoimmune problems. Continue reading →

Children of obese moms beware: your lives may be cut short by heart disease, or other bad health outcomes.

That’s the conclusion of a recent study (observational, but still) published in the BMJ that found an association between women who were obese during pregnancy and their offsprings’ increased risk of premature death in general, and “cardiovascular events” in particular.

From the paper:

With the rising rates of excess weight among pregnant women, our findings of an association between maternal overweight and obesity and premature death in the adult offspring is a major public health concern. The offspring of mothers with increased BMI also experienced significantly more hospital admissions from all cardiovascular events combined…Our results suggest that the intrauterine environment has a crucial and long lasting effect on risk of premature mortality in offspring.

(lunar caustic/flickr)

We’ve written previously about the various health woes you’ve never even imagined that obese pregnant women face: an increased risk of still births, birth defects, infections, pediatric asthma, abnormal fetal brain development and this list goes on.

You knew this, but more and more evidence is emerging that subtle shifts in the environment inside a pregnant women’s womb can have an enormous impact on your child’s future health.

From the BMJ editorial accompanying the study by Pam Factor-Litvak, associate professor of epidemiology at Columbia University, which asserts that interventions to combat obesity must begin well before pregnancy, here’s a bit about why womb conditions matter:

As with maternal undernutrition, maternal overnutrition and obesity are associated with definite changes in the intrauterine milieu, such as increased circulating cytokines, glucose concentrations, and lipids, as well as increased insulin resistance—all of which may lead to an increased supply of nutrients to the developing fetus. Continue reading →

First the bad: in a new analysis, male baldness is linked to an increased risk of heart disease, the online journal BMJ Open reports.

(world on jan/flickr)

The silver lining: the risk is greatest for men with a “thinning crown” as opposed to a receding hairline, the study finds. Indeed, receding hairlines aren’t linked to a higher risk at all.

Researchers suggest several possible explanations: such baldness may be a sign of insulin resistance (implicated in diabetes); chronic inflammation or a heightened sensitivity to testosterone, “all of which are involved directly or indirectly in promoting cardiovascular disease.”

More from the BMJ news release:

Male pattern baldness is linked to an increased risk of coronary heart disease, but only if it’s on the top/crown of the head, rather than at the front, finds an analysis of published evidence…

A receding hairline is not linked to an increased risk, the analysis indicates.

The researchers trawled the Medline and the Cochrane Library databases for research published on male pattern baldness and coronary heart disease, and came up with 850 possible studies, published between 1950 and 2012.

But only six satisfied all the eligibility criteria and so were included in the analysis. All had been published between 1993 and 2008, and involved just under 40,000 men. Continue reading →

Jones discusses the shaky evidence base for many of the most common heart disease treatments, from bypass surgery to angioplasty and stents.

…“Patients are wildly enthusiastic about these treatments,” he says. “There’ve been focus groups with prospective patients who have stunningly exaggerated expectations of efficacy. Some believed that angioplasty would extend their life expectancy by 10 years! Angioplasty can save the lives of heart-attack patients. But for patients with stable coronary disease, who comprise a large share of angioplasty patients? It has not been shown to extend life expectancy by a day, let alone 10 years—and it’s done a million times a year in this country.” Jones adds wryly, “If anyone does come up with a treatment that can extend anyone’s life expectancy by 10 years, let me know where I can invest.”

“The gap between what patients and doctors expect from these procedures, and the benefit that they actually provide, shows the profound impact of a certain kind of mechanical logic in medicine,” he explains. “Even though doctors value randomized clinical trials and evidence-based medicine, they are powerfully influenced by ideas about how diseases and treatments work. If doctors think a treatment should work, they come to believe that it does work, even when the clinical evidence isn’t there.”

It seemed to make perfect sense. If HDL cholesterol is good, then higher levels of HDL are better, right? Alas, no, according to a potentially game-changing study published in the medical journal The Lancet. As things tend to go in medicine, it’s far more complicated.

Researchers at The Broad Institute and Massachusetts General Hospital found that people with higher genetic levels of the good cholesterol HDL don’t necessarily have more protection or a lower risk of heart disease.

What they found was surprising. Individuals who carried a particular variation in a gene called endothelial lipase had HDL levels that were elevated about 6mg/dl, or 10% — a change expected to decrease heart attack risk by about 13%. However, these individuals showed no difference in their risk of heart disease compared to people without the variant. Continue reading →

In a nutshell: A review of previous studies found that “implanting stents, tubes used to prop open a blocked artery, in patients with stable coronary artery disease was no more effective than using medications.” (That review was in the Archives of Internal Medicine of Feb. 27, and here’s the New York Times report.)

A day later, a study in the Journal of General Medicine found, as Chelsea sums it up, “Few Medicare patients who had a coronary artery stent implanted said doctors spent time discussing alternatives.” The press release for the study was even a bit more dramatic, describing the findings like this:

Nine out of 10 Medicare patients who received a stent procedure for coronary artery disease report their physicians didn’t present them with an alternative of managing their condition with medication, according to results of a survey published online today by the Journal of General Internal Medicine.

The study concludes that patients are not always fully informed of their treatment options, and physicians should increase efforts to involve patients in decisions before performing elective procedures. For example, stenting can provide relief from chest pain, but comparable benefits for most patients can be achieved with good medical management and lifestyle changes, as noted in another study published last week.

I agree absolutely with all the people who denounce health coverage as an endlessly flip-flopping see-saw going back and forth between “Eat more X,” and “Don’t eat X.” Drink wine. No, don’t. Fat is bad. No, carbs are bad. Vitamins are good for you. No, they may be bad. I could go on.

But such is the nature of the kind of epidemiological research that yields many of the findings that are translated into health recommendations. It’s messy, complex, difficult work that tries to lurch toward some kind of consensus, and we follow its results like the audience at a baseball game, seeing the score at the end of each inning but not knowing what the final count will be.

All of which is a long-winded preamble to the fact that I published this post about a prime proponent of Vitamin D last week, and now would like to pass along new findings by researchers from Brown University and elsewhere that are less enthusiastic about Vitamin D’s potential broad health effects.

From Brown:

“A study of postmenopausal women found no significant mortality benefit from vitamin D after controlling for health risk factors such as abdominal obesity. The only exception was that thin-waisted women with low vitamin D levels might face some risk. The results, based on data in the Women’s Health Initiative and published online in the American Journal of Clinical Nutrition, agree with advice issued last year by the Institute of Medicine that cautioned against vitamin D having a benefit beyond bone health.”

PROVIDENCE, R.I. [Brown University] — Doctors agree that vitamin D promotes bone health, but a belief that it can also prevent cancer, cardiovascular disease and other causes of death has been a major health controversy. Continue reading →

Kara Kennedy’s wake is to be held this evening, and her funeral tomorrow. She was the 51-year-old daughter of the late Sen. Ted Kennedy, the mother of two and a long-time lung-cancer survivor. She died at her Washington, D.C. health club last Friday of an apparent heart attack, reportedly after her daily work-out.

Her death caught my attention for two reasons. First, the obvious: It was yet another Kennedy death at a tragically young age. The second was more personal: A close relative had just been caught in an oddly similar circumstance.

He’d started feeling woozy and weak right after a work-out, and may have saved his own life by going to the emergency room. It turned out an artery was almost entirely blocked, and he needed a catheterization and a stent. When I mentioned his experience to a colleague, I got an immediate echo: Yes, she said, our co-worker had exactly the same thing happen right after he got off the stairmaster.

Hmmm. Is there a danger zone right after exercise? Why would that be, when the greatest exertion load is already off? I spoke today with Dr. Aaron Baggish, a Massachusetts General Hospital cardiologist and expert on the effects of exercise on the heart and cardiovascular system. (Also himself a competitive runner, and the cardiologist for the Boston Marathon.)

‘Probably 25% of the total workout time should be spent in warm-up and cool-down.’

His edifying explanations follow, but here’s my own takeaway: I am never, ever going to work out again without allowing time for a cool-down period of at least 10 minutes or so. Constantly feeling pressed for time, I tend to skip the warm-up and shortchange the cool-down in favor of getting in my 30-plus minutes of hard cardio. No more.

Note: This is in no way to imply that Kara Kennedy may have failed to cool down properly. She sounds like she was doing everything right for her health. I’m just sharing what I’ve learned for myself, and what sticks in my mind most was the case of a man Aaron just saw in the ICU — a fit, middle-aged man who’d just had a heart attack after playing tennis. In a rush, the man jumped right into a super-competitive match, and the minute it ended, he got into his car, where he started having chest pain. The crux of the problem was that he hadn’t had time to warm up or cool down.

So is there a danger zone right after a workout?

The short answer is yes.

The more complete answer is that there’s no question that routine cardiovascular exercise is the best way to reduce your risk of having a heart problem. The paradox here is that if you do exercise, you’re most likely to have your heart problem either during or immediately after your workout.

There are two reasons for that. One is that people are more likely to notice symptoms, particularly of coronary disease, when exerting themselves. The second is that if people are going to have an acute closure of their coronary arteries, exercise can be the trigger for that.

Why would that be?

The reasons that a coronary artery would suddenly collapse or close up is that a blood clot would form at an area of prior instability.

The process of artery-narrowing involves a collection of cholesterol and blood cells in the wall of the artery. Those areas are weak, the artery wall is weak, and so with the stress of exercise, you’re actually likely to rupture those areas and a blood clot will form there. Continue reading →

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Massachusetts is the leading laboratory for health care reform in the nation, and a hub of medical innovation. From the lab to your doctor’s office, from the broad political stage to the numbers on your scale, we’d like CommonHealth to be your go-to source for news, conversation and smart analysis. Your hosts are Carey Goldberg, former Boston bureau chief of The New York Times, and Rachel Zimmerman, former health and medicine reporter for The Wall Street Journal.

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